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Rural Colorado Shows How Vaccination Messaging Is A Science In Itself

Rae Ellen Bichell
Mountain West News Bureau

This article was produced as a project for the USC Annenberg Center for Health Journalism’s 2019 Data Fellowship.

A vaccine against the virus behind COVID-19 offers the only certain return to normalcy. Even so, misinformation and conspiracy theories abound – and a vaccine hasn’t even been developed yet. It’s an issue people have been trying to combat for other vaccines that do exist. Colorado researchers are taking an interesting approach to bridge the gap.

Back in February at the Durango Public Library, Dr. Mandy Dempsey addressed a room of 14 future vaccine ambassadors.

“The goal of this part is to get everybody on the same page in terms of their knowledge and understanding about adolescent vaccination, which is the reason why we’re here today,” she said.

In this area and other rural counties, adolescents in particular are missing vaccines.

Nationally, only about half of adolescents are fully vaccinated against HPV, and according to 2018 data from the Centers for Disease Control and Prevention there’s a big gap between rural and urban teens when it comes to vaccines, including the one that protects against HPV and the one that protects against four types of meningitis.

In La Plata and Archuleta counties, for example, state data shows that only 40% and 27% of teens are up to date on HPV vaccines. And doctors and researchers are somewhat stumped about how to increase those percentages. There’ve been plenty of studies about how to communicate with parents, but they haven’t provided the straightforward answers public health might have hoped for.

For example, Dempsey told the room, “I’m gonna tell you about this interesting study that was a national study of parents, and this was about the MMR vaccine. That’s the measles, mumps, rubella vaccine.”

Rae Ellen Bichell
Mountain West News Bureau

Researchers wanted to know: What information would get parents to vaccinate their kids? They sent a web survey to more than 1,700 U.S. parents, and split them into five groups. One group got a paper about how MMR does not cause autism. Another got a detailed information sheet about the vaccine.

“A third group got pictures of children that had measles, mumps, and rubella, and a little explanation like, ‘Hey, these are the diseases that we want to prevent,’” Dempsey said. “And then the fourth group didn't get pictures, but they got this emotional story from a parent who had a child who had a really severe case of measles and what that was like for them.”

Finally, a control group got information about something unrelated to the MMR vaccine.

“So, who wants to guess which one of these was the most effective message?” Dempsey asked.

“Three,” someone said, referring to the pictures of measles, mumps and rubella. “Four,” said a high schooler – the emotional story from a parent.

“Well, what happened was that actually none of the interventions worked,” said Dempsey. “Isn't that depressing.”

The room filled with nervous laughter. And in fact, Dempsey continued, in some cases it actually backfired. As the researchers wrote in the journal Pediatrics, giving parents evidence that the MMR vaccine doesn’t cause autism “successfully reduced misperceptions that vaccines cause autism,” but at the same time, among the parents who were most hesitant about vaccines to begin with, it “decreased intent to vaccinate.”

“Nobody knows why that happened,” said Dempsey.

“In addition,” as the researchers wrote, “Images of sick children increased expressed belief in a vaccine/autism link and a dramatic narrative about an infant in danger increased self-reported belief in serious vaccine side effects.”

But Dempsey was clear: Describing studies like these is not meant as discouragement. It’s meant as a rallying cry, because there is no silver bullet for getting people to vaccinate more. They need local solutions.

“And so that’s why I think thinking about it at a community level – at a more micro level – is so important,” she said. “Because it really is influenced by where you live and who's around you and kind of what's going on in your day-to-day life, what the culture is like in your environment.”

Rae Ellen Bichell
Mountain West News Bureau

The six-hour meeting was just the first of many to take place over the course of many months in a process called Boot Camp Translation, and the goal is for this team of people – parents, high schoolers, college students, school nurses – to figure out what messages will work to boost vaccination in their area.

“Now we're at the start of the boot camp,” said Dempsey. “Yay!”

Dempsey is a professor of pediatrics at the University of Colorado and a practicing pediatrician with Children’s Hospital Colorado. The main concern for this bootcamp is adolescent vaccination, especially the vaccine against HPV, the one that protects against a family of viruses that can cause cancer in the mouth, throat, cervix, penis, vagina and anus.

“This is a cancer that impacts women at the prime of their life,” said Dempsey at the meeting. But, she added, “HPV affects both genders pretty significantly. It's not just a women's problem.”

Who knows what the group may come up with to try to close the vaccination gap, said Dempsey. “Things that have been created in the past have been, you know, coffee mugs that the doctor's office gives out or posters that you put at the bus stop.”

In an earlier study in the Denver and Grand Junction areas, the two communities took different approaches. In Grand Junction, the researchers wrote, “Participants believed that vaccine hesitancy in Mesa County partially stemmed from the understanding of HPV as a sexually transmitted infection that young adolescents would not be exposed to yet,” and chose to focus their advocacy on the importance of preventing cancer and “the ability to make one’s own health care decisions.” In Denver, participants decided to focus on parents of elementary school children, and their campaign emphasized how the vaccine is more effective when given at a younger age. They also “agreed that messages would be most effective when delivered by peers in community locations that are frequented by parents, such as recreation centers, churches, food banks, and schools.”

Whatever the Durango area group comes up with, the researchers will see if the campaign corresponds with a boost in vaccination. The researchers are doing the same process with three other rural communities in western Colorado. They’ll compare before and after vaccination rates against four control groups: rural western Colorado communities that did not participate in Boot Camp Translation.

Colorado records show less than half of teens are fully immunized against HPV in the area surrounding Durango, Colo.
Colorado records show less than half of teens are fully immunized against HPV in the area surrounding Durango, Colo.

Dr. Jack Westfall and his colleagues pioneered this community solutions method in Eastern Colorado.

“This is so exciting to see bootcamp translation get moved over to the Western Slope,” said Westfall. “I think it’s a very good application of this process.”

Back in 2003, he and the High Plains Research Network were focused on the higher rates of colon cancer death in their area than in other parts of the country.

“The community then said, ‘Well, you know, here's the deal. We need to understand more about colon cancer, about colorectal cancer screening before we would ever be able to come up with an intervention to improve the screening rates in rural Colorado,’” he said.

So, they brought in a doctor for a few hours of presentations so local farmers, ranchers, school teachers and business owners could learn more about colon cancer

“And then they found out that if you do a colonoscopy and you find a polyp and you remove it, you can actually prevent colon cancer from progressing,” said Westfall. “So it's not just about finding cancer, it's about potentially preventing cancer.”

The community decided to ditch the medical jargon and come up with messaging that would encourage people to get tested more. They ended up publishing personal stories in local newspapers. They made mugs that said “Got polyps?” instead of “Got milk?” And they distributed flyers at farm auctions.

“And within a couple of years, the testing rates in those communities had gone up 10%,” said Westfall.

Since then, the method has been used in a number of communities across the country, on issues like asthma, high blood pressure, birth control and now vaccines.

Jennifer Reich, a sociologist at the University of Colorado Denver who wrote a book about why parents reject vaccines, said this approach may be promising for childhood immunizations, because at the end of the day, immunization choices tend to be very local.

“We know that information tends to cluster and that groups of parents tend to share health practices together, whether it's nutrition or vaccine practices or child soccer teams,” said Reich.

And Reich said in some ways, figuring out what works for certain communities matters in a big way right now, as progress continues on a potential vaccine against the virus that causes COVID-19, and surveys from organizations including Pew and the Associated Press show that hesitancy abounds.

“Any training and tools for healthcare providers on how to communicate effectively with families and their practices matter,” said Reich.

And, Reich added, it’s important for people not just to get their kids vaccinated more, but to feel good about that decision.

“Even if people consent to the vaccine, it doesn't necessarily mean they feel good about that choice,” she said. “They have to feel secure in their decision making and that the information they had was accurate was objective and was not in any way influenced by conflicts of interests. They need to believe that the people offering information don't personally benefit from one kind of information or another.”

In that way, local solutions that rely on peer messaging could prove fruitful.

Dempsey and her colleagues expect the messaging campaigns to launch in the fall, and to have results about whether they worked by early 2022.

This story was produced by the Mountain West News Bureau, a collaboration between Wyoming Public Media, Boise State Public Radio in Idaho, KUNR in Nevada, the O'Connor Center for the Rocky Mountain West in Montana, KUNC in Colorado, KUNM in New Mexico, with support from affiliate stations across the region. Funding for the Mountain West News Bureau is provided in part by the Corporation for Public Broadcasting.

Rae Ellen Bichell was a reporter for KUNC and the Mountain West News Bureau from 2018 to 2020.